JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Goro Matsumiya Vol. 53, No. 2, March 2024 CONTENTS

Preface

• Surgical Treatment for Advanced Heart Failure Is Facing a Big Tide of Transition in Japan　M. Ono

Originals

• Impact of Hospital Integration on Emergency Surgery Patients with Stanford Type A Acute Aortic Dissection　H. Nakai et al. 　49
  Impact of Hospital Integration on Emergency Surgery Patients with Stanford Type A Acute Aortic Dissection
  

  Hidekazu Nakai＊	Hidetaka Wakiyama＊＊	Makoto Kusakizako＊＊
  Daiki Kato＊＊	Ryota Takahashi＊＊	Yousuke Tanaka＊＊
  Ayako Maruo＊＊	Hidehumi Obo＊＊

  
  

  (Cardiovascular Surgery, Ako City Hospital＊, Ako, Japan, and Cardiovascular Surgery, Kakogawa Central City Hospital＊＊, Kakogawa, Japan)
  

  Objective: Hospitals throughout Japan are being integrated and reorganized under the government’s regional medical care plan. However, the effects on cardiovascular surgery practice remain unknown. In the year 2016, our institution employed hospital integration; we report its effects on patients with type A acute aortic dissection who underwent emergency surgery. Methods: This study included 89 patients who underwent emergency surgery for type A acute aortic dissection from May 2012 to December 2020. Evaluation items included preoperative patient factors, number of surgeries, surgical mortality, referral rate, patient transport time, transport distance, number of surgeries performed by young cardiovascular surgeons, and overtime work for surgery. Patients were categorized into pre- （group P: 29 patients） and post-integration （group A: 60 patients） groups, which were retrospectively compared. Results: Preoperative factors were not significantly different between the two groups. Operations accounted for 29 and 60 in groups P and A, respectively; they increased significantly after integration （p＝0.005）. Surgical mortality was 27.6 and 15% in groups P and A, respectively, with no significant difference （p＝0.2）. The referral rate was 17 （58.6%） and 21 （35%） patients in groups P and A, respectively; group A displayed a significantly lower referral rate （p＝0.04）. The interval from the onset of symptoms to arrival at the surgery cite was significantly reduced （p＝0.01） in group A （112±140 min） compared to group P （206±201 min）. There was no significant difference in the transfer distance between groups P （13.9±14.8 km） and A （13.5±16.2 km）. The number of surgeries performed by young surgeons increased in 9 cases （31%） in group P and 34 cases （56.7%） in group A （p＝0.02）. Overtime work was substantially reduced:446±154 min in group P and 349±112 min in group A. Conclusion: Hospital integration resulted in increased number of acute aortic dissection surgeries and decreased interval time from the onset of symptoms to arrival at the surgery cite. The young surgeons performed more surgeries and reduced their overtime work.

   

  Jpn. J. Cardiovasc. Surg. 53: 49-55（2024）

  Keywords：hospital integration; acute aortic dissection; regional medical care; acute aortic syndrome

  
  
• Modified Sternum-Closing Procedure with Titanium Cable and a Poly-Lactic Acid (PLA) Mesh Plate－For Improving QOL after Cardiac Surgery in Patient with Sternotomy　T. Higaki et al. 　56
  Modified Sternum-Closing Procedure with Titanium Cable and a Poly-Lactic Acid （PLA） Mesh Plate―For Improving QOL after Cardiac Surgery in Patient with Sternotomy
  

  Tomohide Higaki＊	Hirotsugu Kurobe＊	Takuma Fukunishi＊
  Tomohisa Sakaue＊	Takashi Nishimura＊	Hironori Izutani＊

  
  

  (Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine＊, Toon, Japan)
  

  Background: Unstable sternal fixation following sternotomy is one of the risk factors that affects postoperative outcomes in cardio-thoracic surgery and is associated with increased risk of infection, bleeding and delayed rehabilitation due to pain associated with sternal movement. Sternal plate systems, which help stabilize fixation, has been limited in use due to patients’ comorbidities, such as diabetes mellitus （DM） and obesity. The conventional wire sternal-fixation procedure, which depend on years of physician’ experience, raise concerns such as unstable sternal fixation due to uncompleted wire twisting. Therefore, a novel sternal-fixation procedure using both titanium cable and a PLA mesh plate was investigated as a potential improvement for sternal closure. We compared the ability of this new sternum fixation procedure （group N） against the conventional sternal fixation procedure using only a wire （group O） to achieve more stable postoperative sternal fixation. Methods and Results: Among adult open-heart surgeries performed between August 2020 and April 2023, 155 patients who underwent postoperative CT were included, with group N being the combined group and group O being the group using conventional metal wires: group N （86 patients: M 65, F 21） and group O （69 patients: M 50, F 19）. Preoperative factors included age at surgery （group N: group O＝68.4±10.6 : 69.6±11.5 years （p=0.25））, BMI （group N: group O＝23.0±3.7 : 24.1±7.7 （p=0.16）） and HbA1c （group N: group O＝6.3±1.1：8.0±10.3% （p=0.10）, and no factors were significantly different between the two groups. The CT analysis at the point of hospital discharge after surgery measured postoperative sternal deviation in the third rib position. Transverse displacement was significantly reduced （group N: group O＝0.22±0.73: 0.83±1.08 mm （p=0.005））, and longitudinal displacement also showed an improvement but the difference was not statistically significant （group N: group O＝0.53±0.86: 0.72±1.14 mm （p=0.13）. Conclusion: A novel sternum closing technique using a tension-anchored titanium cable and a PLA mesh plate demonstrated improved postoperative sternal fixation in a controlled study with 155 patients. This new procedure also enables standardized stable sternal closure with a constant force without relying on conventional empirical sensation and without suppressing sternal cutting, thus contributing to the improvement of postoperative quality of life and prevention of complications.

   

  Jpn. J. Cardiovasc. Surg. 53: 56-61（2024）

  Keywords：titanium cable; mesh plate; sternum fixation

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Case of Three Directional Cuff Leakage from the Stent Posts of an Inspilis RESILIA Aortic Valve during Surgical Aortic Replacement　M. Ikehara et al. 　62
  A Case of Three Directional Cuff Leakage from the Stent Posts of an Inspilis RESILIA Aortic Valve during Surgical Aortic Replacement
  

  Masaaki Ikehara＊	Masaru Kanbe＊	Kozo Morita＊
  Hiroshi Niinami＊

  
  

  (Department of Cardiovascular Surgery, Tokyo Heart Center＊, Tokyo, Japan, and Department of Cardiovascular Surgery, School of Medicine, Tokyo Women’s Medical University＊＊, Tokyo, Japan)
  

  We present the case of a 72-year-old male with Inspiris RESILIA aortic valve （Inspiris） transvalvular leakage during surgical aortic valve replacement （AVR）. The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography （TEE） captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.

   

  Jpn. J. Cardiovasc. Surg. 53: 62-65（2024）

  Keywords： inspiris RESILIA aortic valve; paravalvular leakage; transvalvular leakage; echocardiogram; aortic valve replacement

  
  
• A Case of Takayasu’s Arteritis with Aortic Root Abscess after AVR and during Biologic Drug Administration　S. Kawaguchi et al. 　66
  A Case of Takayasuʼs Arteritis with Aortic Root Abscess after AVR and during Biologic Drug Administration
  

  Shinji Kawaguchi＊	Masanao Nakai＊	Takahiro Ozawa＊
  Daisuke Uchiyama＊	Yuta Miyano＊	Yasuhiko Terai＊
  Muneaki Yamada＊	Ryota Nomura＊	Hiroshi Mitsuoka＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka City Hospital＊, Shizuoka, Japan)
  

  A 32-year-old woman was diagnosed with Takayasuʼs arteritis 5 years ago and underwent aortic valve replacement for aortic regurgitation 1 year ago. She had been taking Prednisolone and Azathioprine for Takayasuʼs arteritis, but these drugs were switched to subcutaneous Tocilizumab 4 months ago. One month ago, she had dyspnea on exertion, and 2 days ago, chest discomfort appeared, and she came to our hospital. Blood tests showed CRP 0.02 mg/dl, and echocardiography and CT showed perivalvular leakage and aortic root pseudoaneurysm, which led us to suspect aortic root pseudoaneurysm due to Takayasuʼs arteritis and to perform emergency surgery. Although a circumferential pseudoaneurysm was observed at the aortic root, no destruction of the prosthetic valve was observed. The suture from the previous surgery was attached to the sawing cuff of the prosthetic valve, and the prosthetic valve was not fixed to the aortic annulus and could be easily removed. The Bentall operation was performed using a bioprosthetic valve. The histopathological diagnosis was subacute infective endocarditis, and the patient was diagnosed with a pseudoaneurysm of the aortic root due to infection. The patient had a good postoperative course and was discharged home on the 19th day. We report a case of Takayasuʼs arteritis with valve annular abscess after AVR, which was treated surgically during biologic drug administration.

   

  Jpn. J. Cardiovasc. Surg. 53: 66-69（2024）

  Keywords：Takayasuʼs arteritis; Tocilizumab; pseudoaneurysm of the aortic root

  
  
• The Use of a Proximal Anastomotic Device to the Side of the Aortic Arch in CABG and AVR : a Case Report　M. Matsuda et al. 　70
  The Use of a Proximal Anastomotic Device to the Side of the Aortic Arch in CABG and AVR: a Case Report
  

  Maiko Matsuda＊	Takahiro Fujimoto＊＊	Mitsuru Yuzaki＊
  Yoshitaka Okamura＊	Yoshiharu Nishimura＊＊

  
  

  (Department of Cardiovascular Surgery, Seiyu Memorial Hospital＊, Wakayama, Japan, and Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University＊＊, Wakayama, Japan)
  

  A 73-year-old woman presented at our hospital with dyspnea. Echocardiography showed severe aortic stenosis and a coronary angiography revealed right coronary artery disease. Therefore, we performed aortic valve replacement （AVR） and coronary artery bypass grafting （CABG） surgery. Proximal anastomosis was initially attempted to the ascending aorta. However, the ascending aorta was thin and weak, we decided to anastomose to the side of the aortic arch. Proximal anastomosis was performed with an anastomotic device. Postoperative coronary computed tomography （CT） showed that the graft was patent.

   

  Jpn. J. Cardiovasc. Surg. 53: 70-73（2024）

  Keywords： coronary artery bypass grafting; proximal anastomosis; clampless proximal anastomotic device; dilated ascending aorta

  
  
• Surgical Treatment of Ruptured Coronary Artery Aneurysm　D. Sato et al. 　74
  Surgical Treatment of Ruptured Coronary Artery Aneurysm
  

  Daiki Sato＊	Yuta Kume＊	Yukihiro Bonkohara＊

  
  

  (Department of Cardiovascular Surgery, National Hospital Organization Yokohama Medical Center＊, Yokohama, Japan)
  

  A 50-year-old man was referred to our hospital due to chest pain and loss of consciousness. Diagnosed with cardiac tamponade, he underwent emergency percutaneous pericardial drainage and endotracheal intubation. AAD was not found, although aortic root dissection was suspected from the CT scan and CAG. The MDCT revealed a 16 mm ruptured coronary artery aneurysm connected to the LMT with a CA-PA fistula. Urgently, coronary artery aneurysmectomy, CA-PA fistula repair, and CABG were performed, and the postoperative course was smooth. Surgery reports for ruptured coronary artery aneurysm are rare, so we report the successful surgical case.

   

  Jpn. J. Cardiovasc. Surg. 53: 74-77（2024）

  Keywords：coronary artery aneurysm; coronary-pulmonary artery fistula; ruptured coronary artery aneurysm

  
  
• A Case of Aortic Homograft Root Replacement for Active Infective Endocarditis Complicated by Multiple Cerebral Infarctions and Disorders of Consciousness　H. Kaneko et al. 　78
  A Case of Aortic Homograft Root Replacement for Active Infective Endocarditis Complicated by Multiple Cerebral Infarctions and Disorders of Consciousness
  

  Hiroyuki Kaneko＊	Shogo Shimada＊	Minoru Ono

  
  

  （Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo＊, Tokyo, Japan）
  

  A 24-year-old man was admitted due to fever for two days. He had undergone modified Bentall operation at the age of 18. Transthoracic echocardiography （TTE） showed no findings of infective endocarditis （IE）, and he was treated with a course of antibiotics. On the next day, he suffered from aphasia and right hemiplegia, and computed tomography （CT） showed left cerebral infarction due to left middle cerebral artery embolism. The emergent endovascular reperfusion was done, but mild subarachnoid hemorrhage occurred. The following day, TTE showed vegetations and aortic annular abscess, and MSSA was confirmed by blood culture. He was transferred to our institution for surgical treatment for IE. High fever continued, and inflammatory response was recurrent, because the infection was not under control. In addition, multiple systemic thromboembolisms were revealed by contrast-enhanced CT. He recovered to the level of moving his limbs slightly, but he could not speak. We did aortic homograft root replacement and coronary bypass grafting 6 days after the cerebral infarction. His postoperative course was uneventful and he was transferred to rehabilitation hospital on postoperative day 31. He reintegrated into society without neurological complications, and there are no recurrent infections and have been no structural valve deteriorations of the homograft in 5 years.

   

  Jpn. J. Cardiovasc. Surg. 53: 78-82（2024）

  Keywords：infective endocarditis; annular abscess; cerebral infarction; disorders of consciousness; homograft

  
  
• A Case of Ventricular Aneurysm in a Remote Stage after Repair of a Ventricular Septal Perforation with Massive Thrombus in the Aneurysm　Y. Endo et al. 　83
  A Case of Ventricular Aneurysm in a Remote Stage after Repair of a Ventricular Septal Perforation with Massive Thrombus in the Aneurysm
  

  Yoshiki Endo＊	Yasuhisa Fukada＊	Hitoshi Nakanowatari＊
  Yoshihito Irie＊

  
  

  (Division of Cardiovascular Surgery, Department of Cardiovascular Surgery, Iwaki City Medical Center, Iwaki, Japan）
  

  A 71-year-old woman underwent repair of a ventricular septal perforation due to myocardial infarction by the extended sandwich patch technique 5 years ago. She was discharged from the hospital without complications. During the follow-up period, a ventricular apical aneurysm was found on contrast-enhanced computed tomography and transthoracic echocardiography. Since the aneurysm had enlarged gradually and a thrombus was found in it, repairing surgery was indicated. The patient was initiated on cardiopulmonary bypass after dissection of the adhesions of the previous surgery, and a longitudinal incision was made on the left side of the left anterior descending artery under cardiac arrest to remove the aneurysm. A large amount of thrombus was found inside the aneurysm. The thrombus was removed, Dor surgery was performed with a circular Hemashield patch. Reports of ventricular apical aneurysm after myocardial infarction in a remote period are rare. It is necessary to perform surgical intervention as soon as possible to prevent free wall rupture as well as cerebral infarction.

   

  Jpn. J. Cardiovasc. Surg. 53: 83-86（2024）

  Keywords： ventricular septal perforation; ventricular aneurysm; Dor surgery; left ventricular thrombus

  
  
• ［Aortic Disease］
• A Case Report of a Ruptured Abdominal Aortic Aneurysm Associated with Thrombosed Acute Type B Aortic Dissection　H. Baba et al. 　87
  A Case Report of a Ruptured Abdominal Aortic Aneurysm Associated with Thrombosed Acute Type B Aortic Dissection
  

  Hironori Baba＊	Ayaka Iwasaki＊	Kosuke Mori＊
  Eisaku Nakamura＊

  
  

  (Department of Cardiovascular Surgery, Miyazaki Prefectural Miyazaki Hospital＊, Miyazaki, Japan)
  

  A 70-year-old man with no outpatient history visited the local doctor with complaints of weakness of the limbs and abdominal pain on the following day after vomiting on the previous night. He was suspected to have a ruptured abdominal aortic aneurysm from a simple CT scan of the abdomen, and was transported to our hospital for emergency treatment. After a contrast-enhanced CT scan at our hospital, a thrombosed type B aortic dissection and ruptured abdominal aortic aneurysm were diagnosed, and emergency surgery was performed on the same day. Although the dissection had extended to the abdominal aortic aneurysm, abdominal aortic endovascular repair （EVAR） was performed because it was a thrombosed type B aortic dissection. After admission to the intensive care unit （ICU）, the patient showed intra-abdominal hypertension and oliguria. So, we performed an emergency decompressive laparotomy against abdominal compartment syndrome （ACS）. He was discharged from the ICU on the 8th day and transferred to rehabilitation on the 38th day. We report a case of a ruptured abdominal aortic aneurysm associated with thrombosed acute type B aortic dissection that was successfully treated.

   

  Jpn. J. Cardiovasc. Surg. 53: 87-90（2024）

  Keywords：Type B acute aortic dissection; ruptured abdominal aortic aneurysm; endovascular repair; abdominal compartment syndrome

  
  

U-40

• U-40 Column
• What Do Young Cardiovascular Surgeons Think about Research ? 　H. Sakurai et al. 　U1

Editor’s Post Script

• S. Miyagawa